Professional dominance? Encounters between physicians and patients in the first half of the 19th century under the Habsburg Monarchy

In Vienna, the tradition of clinical teaching began with Anton de Haen’s introduction of the newly established educational approach in the Buergerspital in 1754. In the second half of the 18th century, clinical teaching at medical faculties contributed to the shift of power relationships between doctors and patients. The medical gaze that the doctor and the patient directed towards each other regulated the patients’ as well as the physicians’ behavior in the setting of hospital medicine, but this does not mean that a wholesale transformation of the medical field took place. Patients were not mere passive objects of externally controlled processes but influential agents of medical process. Middle- and upper-class patients sought assistance from their family general practitioners even at the beginning of the 20th century, and the relationships between these family doctors and their patients were more equal. Up to the end of the 19th century, physician-patient contact often comprised traditional methods of consultation by letter, and physicians saw and treated their patients predominantly in the patient’s homes. A doctor’s medical authority was not solely based on his knowledge, skills, and reputation among colleagues at the medical faculty. As in the early modern tradition of doctor-patient encounters, patients continued to play the role of ultimate arbiter of the performativity of physicians (AU)

Living with asthma in 19th-century France: The doctor, Armand Trousseau, and the patient, Emile Pereire.

Major advances in the French medical system following the French Revolution have stimulated a rich historiography of which Michel Foucault's Naissance de la clinique: une archéologie du regard médical (1963) and Erwin H. Ackerknecht's Medicine at the Paris Hospital, 1794-1848 (1967) are of lasting significance. Changes in the organisation and structure of hospitals accompanied the development and availability of new medical technologies and procedures and encouraged a more intense study of the aetiology and pathology of disease. Theories about asthma and its treatment profited from this dynamic environment as Classical Greek doctrines about the effect of the humours on bodily imbalance gave way to an increasingly more precise understanding of the nature and cause of asthma. The clinician and teacher, Armand Trousseau (1801-1867), who held the chair of Clinical Medicine at the Hôtel-Dieu in Paris and was himself an asthmatic, promoted new theories about the illness and developed innovative ways of dealing with its effects. Among his patients was the banker and financier, Emile Pereire (1800-1875), a lifelong asthmatic. Based on the Pereire Family Archives (hereafter AFP), the case of Emile Pereire provides a preface to the later case of that other, more famous, asthmatic, Marcel Proust.

[Barbers, charlatans, and the sick: The medical plurality of baroque Spain perceived by the picaresque Estebanillo González]. / Barberos, charlatanes y enfermos: la pluralidad médica de la España barroca percibida por el pícaro Estebanillo González.

In order to know about diseases and their medical treatment from the perspective of the patient in Baroque Spanish society, creative literature, especially the picaresque novel, is a valuable source that offers a representation of ideas on medicine and disease that were widespread among the population and difficult to access from other sources. The first-person narrative in the Vida y hechos de Estebanillo González (1646) offers knowledge on three different aspects of the medical world in Europe during the Thirty Years' War: Estebanillo practises various medical professions, appears in the story as a patient and comments on health practices and disease, providing highly useful material to analyze how different fields of medicine are represented in this literary work.

Patienthood in medieval Tuscany: beliefs and cures.

This paper focuses on intersections of holy and sick bodies in the Tuscan Middle Ages to examine how the faithful accessed miraculous cures from contact with, or belief in, the relics of the saints. Rather than examine the relationship between the long dead martyrs (whose relics were abundant), however, it will look at the relationship between relatively recent saints and their devotees. The miracles discussed are traditional-that is, they are found in the lives of many saints and are not exceptional. It is hoped, however, that by concentrating on Tuscany, some insights can be secured on the relationship between Tuscan individuals of the late middle ages and those of their community who were recognised, either officially or through vox populi, as saints.

"This I Suffered in the Short Space of my Life". The Epitaph for Lucius Minicius Anthimianus (CIG 3272; Peek GVn 1166).

Herewith we present an interdisciplinary study of the metrical funerary inscription from the third century CE (CIG 3272; Peek GV 1166). This emotional Greek epitaph reports the short life (from birth to death) of the 4 year old Lucius Minicius Anthimianus. This is the first detailed study since the dissertation by Klitsch (1976). The inscription presents an ideal case for a truly interdisciplinary study of the patient-history, in that its interpretation involves the study of Greek literature and linguistics, epigraphy, social and religious history, and ancient medicine. It also offers ample opportunity to show the contradictions inherent in proposing retrospective diagnosis, without neglecting the relevant information modern medicine has to offer for the interpretation of this case history. We argue that Lucius' father was most probably a physician, that the text of the inscription stems from expert knowledge of ancient medicine and that the traditional retrospective diagnosis of this case, tuberculosis, is an untenable hypothesis.

Patient Function and Physician Function in the Hippocratic Cases.

This chapter looks at the patient cases of the Epidemics as testimonies to the interaction between the physician and the patient. My corpus of reference is the patient cases in fifth- and early fourth-century medical texts, mostly the more elaborated examples offered by Epidemics 1 and 3. A patient case collects information from various sources: the patient's observable behavior and state; his or her account of her disease, its history and the patient's lifestyle; the contribution given by relatives and friends; and, of course, the physician with his judgment, his agenda, his terminology and didactic aims. What remains elusive and hidden is the viewpoint of the patient and his personal experience within, or under the authoritative report compiled by the physician. In this chapter, I survey key stylistic features of these reports, which I see as significant to the reconstruction of the point of view of the ill in his or her encounter with the doctor. My main aim is to extract from these texts as much as possible information about the experience of suffering and patienthood in antiquity. In my analysis I look at the text not only, and not primarily as a definitive pronouncement stemming from the physician's legislating mind, and from the material author's 'pen', nor observations from by-standers and helpers in the sick room, nor even as the plaintive cries from suffering patient, but as a composition in which all the principal actors in the drama of a sickness must contribute.

Voice Pathologies and the 'Hippocratic Triangle'.

Hippocratic authors frequently utilise silence, babbling, lisping and otherverbal signs to diagnose a variety of physical illnesses and predict theircourse. This chapter examines these 'voice pathologies' and evaluatestheir impact on the dialogue between patients and Hippocratic physicians. In short, Hippocratic authors treat patients' voices in two dissonant ways. On the one hand, physicians promote some form of discourse,implicitly relying on patients to report internal sensations resulting fromillnesses. On the other hand, they develop extensive techniques to diminish and downplay this reliance. As a result, Hippocratic authors treatpatients' mouths not so much as the loci of potential subjective expression, but as orifices secreting verbal discharges. They weaken the distinction between the (sonic) effluvia of the mouth and those of other bodilyoutlets, thus bringing verbal output into close conceptual proximity withother types of discharge. Words come to be scrutinised for their quantity,quality and consistency as though they were quasi-excreta of the mouth. (see text). Announce what has happened, discern what is happening and foretellwhat will happen; attend to these things. Practice two things concerningdiseases: help or do no harm. The art consists of three parts: the disease,the diseased and the physician; the physician is the servant of the art; thediseased fights against the disease with the physician (Hipp., Epid.1.5L. 2.634.6-636.4 = Kiülewein 189,24-190, 6).

Case History as Minority Report in the Hippocratic Epidemics 1.

Instead of being self-evident depictions of sickness, ancient medical texts were narratives created from certain points of view and for intended purposes. As a guide for the physician travelling to an unfamiliar community of people, the treatise Airs, Waters, Places anticipated "communal" conditions resulting from seasonal changes, while admitting the possibility of "personal" sickness due to individual lifestyles. Even with its geographical situatedness, Epidemics 1 continued to prioritise population narratives, subsuming sickness within the experiences of the anonymous majority whenever possible. In both its constitutions and case histories, however, patients whose conditions deviated from majority expectations were identified for forensic purposes, so that case histories functioned as minority reports rather than exemplars of how sickness behaved. Such reports guarded against surprising deviations from the rules of prognosis, which could present a threat to the physician's credibility and livelihood as a consequence.

Galen's Anxious Patients: Lype as Anxiety Disorder.

Galen describes a syndrome he associates with an emotion called lype, with specific symptoms and a course that may lead to humoral imbalance, disease, and death. Lype is an emotion that encompasses distress at a loss, as the death of a close friend or the destruction of one's books by fire; but Galen also associates it with chronic worry about a future threat, and a physiology between the emotions of worry and fear (that is, 'anxiety'). Lype can cause a progressive syndrome characterised by insomnia, fever, pallor, and weight loss that can kill patients or degenerate into psychotic illness. This syndrome can be described in modern terms as an anxiety disorder.

Experiencing Madness: Mental Patients in Medieval Arabo-Islamic Medicine.

This paper focuses on the mental patients in Arabo-Islamic Middle Ages. Patients suffering from mental illnesses generated a lot of interest for Arabo-Islamic physicians. The first objective of this study is to identify who were the mentally infirm and to compare the Arab physicians' typologies of mental patients to that of their Greek predecessors. The second part of this paper shifts the focus from theoretical descriptions to case histories and biographical sources, in order to understand how the physicians treated their mental patients, and to find out what was the social impact of this medical approach. Finally, because the special provision for the insane is a distinctive feature of the Islamic hospital, the third part of my paper examines whether the main purpose of these hospitals was the patients' confinement or their treatment.

Interpretations of the Healer's Touch in the Hippocratic Corpus.

This paper analyses gender as an aspect of the role of touch in the relationship between doctors and patients, as represented in the Hippocratic Corpus. Touch is an essential aspect of the ancient doctor's art, but one potentially fraught with concerns over gender: while seeing, hearing, and smelling are also central to the medical encounter, touching is the act that places the greatest demands on the privacy and bodily integrity of the patient. This paper shows--perhaps counterintuitively--that, despite the multiple assertions of gender differences put forward by the authors of the Hippocratic Corpus, these authors make little distinction between touching male and female patients. At the same time, the paper argues that ancient physicians were anxious to avoid the charge that they were harming their patients when they touched them. It demonstrates that male doctors, sensitive as they were to the problems posed by their interactions with female patients, were challenged in different ways when engaging in intimate contact with male patients.

Patience for the Little Patient: The Infant in Soranus' Gynaecia.

Despite advocating perpetual virginity and viewing childbirth as inherently injurious to female health, Soranus' attitude towards the infant in Book 2 of the Gynaecia is remarkably positive. In fact, it is only towards the infant that Soranus displays such consistently positive attitude. This compassionate approach is evident both in the content and the language employed, which is characterised by a striking occurrence of diminutives. His preference here for authorities such as Thracians and Scythians rather than illustrious ones, along with his 'language of the nursery', points to an oral, rather than literary, tradition. Soranus seems to have been the first to write so extensively on childcare; freed from the influence of any earlier tradition, he engaged in a more nuanced vision of childhood, seeing it as a 'blank slate' both physically and mentally, untouched by the faults of adulthood. While the content of Book 2 has been mined for information concerning the practicalities of child-care, it has not been evaluated in terms of its differences from the rest of the Gynaecia, which are significant.

Compassion in Soranus' Gynecology and Caelius Aurelianus' On Chronic Diseases.

Compassion is considered an important quality for a successful physician today, but did ancient physicians display and value this emotion? How did they feel when faced with the pain and suffering of their patients? How did their patients' emotions affect their own? Many ancient physicians are not well-known for expressions of compassion in their writings; however, this seems to change in the second century AD. One medical writer who exemplifies this change is Soranus of Ephesus (c. 98-138 AD). In his Gynecology, there are a number of passages where compassion is addressed or expressed (such as the chapters on the qualities of the best midwife, the symptom of pica, childbirth, and superstition). The same points can be made of Soranus' On Chronic Diseases, preserved to some extent by the Latin version and adaptation by fifth century AD medical writer Caelius Aurelianus (see, for example, the chapters on chronic headache, mania and elephantiasis). Soranus and Caelius display compassion, understanding, and flexibility of approach when dealing with patient issues; they show themselves willing to change their medical technique when they see that it is doing more harm or discomfort than good. In Soranus and Caelius, we have an image of a physician who acknowledges and is aware of their patients' emotions, beliefs and attitudes, and who exhibits compassion for them.

Galen on the Patient's Role in Pain Diagnosis: Sensation, Consensus, and Metaphor.

Pain might be a powerful diagnostic tool, but it is at the same time an intensely private and subjective experience that represents a formidable problem in the communication between physician and patient. Galen addresses (principally in De locis affectis) the problem of constructing a consistent and univocal terminology for different pain sensations, rejecting the system proposed earlier by Archigenes on the grounds that he relies on metaphorical descriptors which indiscriminately incorporate terms belonging to information generated by all the senses, fails to conform to patient testimony, and refers to ambiguous concepts. Galen sets himself the task of developing a system of proper or literal (kyrios) terms for pain sensations, even despite the apparent ineffability of certain sensations and laymen's imprecise self-analysis and description of their suffering. His pain vocabulary, developed through a combination of consensus between patients and physicians' expert descriptions of their own pain, promises to link terminology univocally to sensation, turning patients' testimony about their subjective experience of pain into universally applicable diagnostic guidance.

The (see text) in the Praecepta: The Medical Fee and its Impact on the Patient.

The brief collection of deontological guidelines entitled Praecepta is one of the most important literary evidence regarding the fee of the ancient physician. This chapter focuses on three passages from the Praecepta, which offer us a wealth of information on this topic. Some technical terms used in the text, such as the term µiσθápiov, show clearly that the author intends both to provide guidelines for the ideal bedside manners and to defend the repute of the physicians from the widespread charge of greed. In some regards, the author of the Praecepta depicts medicine as a 'liberal' art: the good physician disdains monetary gain as the main goal of his service, and aims to safeguard the social status and reputation of the medical profession. On the other hand, the author of the Praecepta enlightens his readers on the bad behaviour of both charlatan physicians and bad-mannered patients.

The Practical Application of Ancient Pulse-Lore and its Influence on the Patient-Doctor Interaction.

This paper examines the effects of the emergence of pulse measurement as an essential diagnosis and prognosis method used on Graeco-Roman patients. It argues that the introduction of this diagnostic tool brought about changes to the encounter between patients and their doctors and may have also increased intimacy and patients' forthcomingness during these encounters. The paper demonstrates that the popularity and conspicuity of the practical and theoretical engagement with the pulse afforded many opportunities for the transmission of professional knowledge from doctors to patients. It argues that this transmission of knowledge was often actively encouraged by doctors for the sake of self-promotion and promotion of the medical profession as a whole. At the same time, doctors also attempted to restrict this transmission of knowledge in order to use their exclusive competence in the pulse as means for establishing their authority and superiority over patients.

Images of Doctors and their Implements: A Visual Dialogue between the Patient and the Doctor.

Images of physicians, patients, and medical instruments were placed on Graeco-Roman funerary monuments, altars and fresco paintings. These representations are examined here to determine whether there existed a standard convention by which physicians were depicted in order that the lay and possibly illiterate viewers could identify what the scene represented. Greek physicians were frequently shown with cupping vessels, midwives were seen with birthing stools, while Roman physicians were often shown with various surgical implements. It is argued that the correlation between the types of objects depicted with the medical practitioner was deliberately made by the artist to signify the nature of medicine the individual practiced, so that the viewer could identify the role the practitioner had in their society.

Treatment of the Man: Galen's Preventive Medicine in the De Sanitate Tuenda.

Ideally in Galen's model of preventive medicine, the patient does not become a patient at all but remains a healthy person able to maintain his or her health without need of either medicines or other therapies. This chapter is divided into four sections, Galen's ideal patient; less than ideal patients; patients in old age; and patients whose nature is inclined to a bad mixture of humours, and so in need of medication. In all four categories, even those where medical recommendations such as blood-letting are recommended, Galen offers an option based on hygieine, or the art of maintaining good health. Galen's aim in de sanitate tuenda is to ensure that a well-educated person can lead a healthy life by learning what does harm and what benefits him or her. The chapter explores the extent to which the patient can really be independent of the doctor, and the interesting balance between nature and urban life which constitutes good health in Galenic thought.